Endoscopic ultrasonography-guided bilateral drainage with antegrade stenting in patient with malignant hilar biliary obstruction after bowel reconstruction

Endoscopic ultrasonography-guided hepaticogastrostomy (EUS-HGS) and uncovered self-expandable metal stent (SEMS) placement between the right and left intrahepatic bile ducts, called the bridging method, is useful for bilateral drainage in patients with malignant hilar biliary obstruction [1]. Combined EUS-HGS and EUS antegrade stenting is reported to reduce the rate of bile leakage and to prolong stent patency [2]. Access from B2 makes it easier to operate the guidewire downstream of the bile duct than from B3, and the use of a forward-viewing echoendoscope reduces the risk of transesophageal puncture [3].

A 50-year-old man who received chemotherapy for recurrent pancreatic cancer presented with jaundice. Subtotal stomach-preserving pancreaticoduodenectomy was performed with Child’s reconstruction. Contrast-enhanced computed tomography showed multiple liver metastases; one metastatic lesion obstructed the hilar part of the bile duct ([Fig. 1]). The bridging method and antegrade stenting using a stent-in-stent technique under EUS guidance were selected. Considering guidewire manipulability, we selected the B2 route; however, use of a curved linear array echoendoscope was associated with a risk of transesophageal puncture. Use of a forward-viewing echoendoscope (TGF-UC260J; Olympus Medical, Tokyo, Japan) enabled us to puncture B2 with a 19-gauge fine-needle aspiration needle (EZ Shot 3 Plus; Olympus Medical). Assisted by an uneven double-lumen cannula (UDC; Piolax Medical, Kanagawa, Japan), we placed two 0.025-inch guidewires (VisiGlide 2; Olympus Medical) into the jejunum and B8 bile duct ([Fig. 2]). First, we placed the initial uncovered SEMS (8 × 60 mm, ZEOSTENT V; ZEONMEDICAL, Tokyo, Japan) using the bridging method ([Fig. 3]). Subsequently, the guidewire was inserted into the jejunum through the mesh of the initial SEMS, then the second uncovered SEMS (8 × 40 mm, ZEOSTENT V) was placed as antegrade stenting using the stent-in-stent technique ([Fig. 4]). Finally, a 7-Fr plastic stent (TYPE-IT; Gadelius Medical, Tokyo, Japan) was placed across the EUS-HGS fistula ([Video 1]). There were no adverse events and jaundice improved immediately.

Fig. 1 Contrast-enhanced computed tomography showed that multiple liver metastases invaded the hilar part of bile duct (arrowheads).

Fig. 2 Assisted by the double-lumen cannula, two 0.025-inch guidewires were inserted into the jejunum from the tip lumen and into the B8 bile duct from the side lumen.

Fig. 3 An uncovered self-expandable metal stent (SEMS) was placed bridging from the right to left intrahepatic bile ducts.

Fig. 4 A second uncovered self-expandable metal stent (SEMS) was placed through the mesh of the first uncovered SEMS into the jejunum to provide antegrade stenting.

Video 1 Endoscopic ultrasonography-guided bilateral drainage with antegrade stenting using the stent-in-stent technique in a patient with malignant hilar biliary obstruction after bowel reconstruction.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Ogura T, Sano T, Onda S. et al. Endoscopic ultrasound-guided biliary drainage for right hepatic bile duct obstruction: novel technical tips. Endoscopy 2015; 47: 72-75
• 2 Imai H, Takenaka M, Omoto S. et al. Utility of endoscopic ultrasound-guided hepaticogastrostomy with antegrade stenting for malignant biliary obstruction after failed endoscopic retrograde cholangiopancreatography. Oncology 2017; 93: 69-75
• 3 Fusaroli P, Ceroni L, Caletti G. Forward-view endoscopic ultrasound: a systematic review of diagnostic and therapeutic applications. Endosc Ultrasound 2013; 2: 64-70

Publication History

Article published online:
24 August 2022